Failure to Accurately Transcribe Insulin Order and Monitor Blood Glucose Leads to Hypoglycemic Event
Penalty
Summary
The facility failed to ensure that nursing staff provided services in accordance with professional standards of quality for a resident with diabetes who was receiving insulin. Upon admission from a local hospital, the resident had a physician's order for Lantus insulin at 5 units daily. However, an LPN inaccurately transcribed this order into the electronic medical record and medication administration record (MAR) as 30 units daily. This error was not identified or corrected, and the resident received the incorrect, higher dose of insulin for several days. Additionally, the nursing staff did not clarify or implement blood glucose monitoring orders for the resident, despite the resident being diabetic and receiving insulin. The hospital discharge orders included a discontinuation of blood glucose checks, but the facility's standing orders required blood glucose monitoring for residents on insulin. Staff did not seek clarification from the physician regarding this discrepancy, nor did they refer to the facility's standing orders. As a result, no blood glucose levels were monitored or documented for the resident during the period in question. On the day of the incident, the resident exhibited a change in condition, including sleepiness and drooling. Despite these symptoms, the nurse on duty did not obtain a blood glucose level. It was only after the resident's family intervened that emergency services were called, at which point a paramedic found the resident's blood glucose to be critically low. The resident was treated for hypoglycemia and transferred to the hospital. Interviews and record reviews confirmed that the errors in transcription, lack of blood glucose monitoring, and failure to respond appropriately to a change in condition directly led to the resident's hypoglycemic event.